Division of Industry Services - Wisconsin

1 Division of Industry Services Application for General Plumbing Plan Review and Cross Connection Assembly Registration -Complete all pages- General Plumbing NOTE: Personal information you provide may be used for secondary purposes [Privacy Law s. (1)(m), Stats.]. 1. For pre-scheduling of plumbing plans, use the electronic online request for plumbing plan appointments found at This form is to be used only for mailing or dropping off plans without an appointment. If you are pre-scheduling a revision, email this completed form to: Check our website at for the most current version of this form. We may re-distribute plans to another office if needed to reasonably balance turnaround times. You may monitor the status of your plan at: Desired Appointment Date: Previously Related Transaction #.

2 Plan Type: New Permission to Start (sections 5 & 15) See our website for next available appointment at Addition/Alteration Revision to Previously Approved plan where approved construction has not been completed. (section 15) Extension to an approved plan. (section 15). Requesting plan review for: OFFICE USE: (Please check the specific plumbing components below). Trans ID: _____. *Storm systems that include infiltration require a separate plan submittal. Site Specific: Building Specific: Complaint Case #: _____. Sanitary Sewer; (section 13) Interior Sanitary DWV; (section 7). Assigned Reviewer: _____. Private Interceptor Main Sanitary Interior Water Distribution; (section 8). Sewer; (section 13) Interceptors; (section 9) Assigned Office: _____.

3 Water Service; (section 13) CCC; (section 10). Reviewer Start Date*: _____. Private Water Main; (section 13) Water Treatment; (section 11). Storm Sewer*; (section 13) Other: Storm Detention*; (section 13) Campground; (section 14). Storm Infiltration*; (section 13) Manufactured Home Park; (section Storm Inlets* (section 13). 14). 2. Project Information Fill in all known information Project/Site Name: Number & Street: County: City/Town/Village: 3. After plans are reviewed please: (check all that apply). Call Customer 1 2 3 Make checks payable to: Industry Mail plans to Customer 1 2 3 (Check only one) Services Division and attach to the Requesting party will pick up application and plans. Plans to be E-filed SharePoint User Name is: 4.

4 Complete the following customer information in the boxes below and on the next page. Designer Information (Customer 1) (Person who stamped Invoice Designer, who will be personally responsible for the plan) payment. Customer ID. Submitter acknowledges that submittal is complete. Last Name Designer Signature: _____. First Name Company Name Total amount due from page 2 $. Street Address Total amount due from page 3 $. City State Total amount due from page 4 $. Zip Total amount due $. Phone Number Email Address Revenue Code 7657. Continue Customer Information and Building Specific Items on Next Pages SBD-6154 (R3/19). Page 1. Building Owner Information (Customer 2) Contact Person or Other, Please Specify (Customer 3).

5 Customer ID. Customer ID. Last Name Last Name First Name First Name Company Name Company Name Street Address Street Address City City State State Zip Zip Phone Number Phone Number Email Address Email Address 5. OPTIONAL SERVICE-PERMISSION TO START. Optional Service-of Permission to Start Requested: As the building owner, I request to begin plumbing installations prior to plan review approval I agree to make any changes required after plans have been reviewed, and to remove or replace any non-code complying construction and make revisions to plans on any changes. I will not permit any installation to exceed 18 inches above the unexcavated floor. Request is for the following specific plumbing installations: Sanitary Sewer.

6 Private interceptor main sewer(s);. Storm Sewer;. Water service;. Private water main;. Interior building drain;. Interior water service;. Interior water distribution. Building Owner's Signature: _____ Date: _____. SUBMIT ADDITIONAL PAGES FOR EACH NON-IDENTICAL BUILDING OR TENANT SPACE. 6. BUILDING SPECIFIC INFORMATION. Indicate here the total number of interior fixtures, including roof drains and hose bibs being submitted for this building: TOTAL #. Sovent/Provent, 13D Multi-Purpose Piping Siphonic roof drain systems Structure is greater or equal to 5 stories in height Project is Apartment/Condo only Healthcare and Related Facility Multiple identical buildings Number of identical buildings being submitted on the same site Indicate Identical Building/Tenant Designation for Each Building and/or Tenant Space (Attach Additional Pages if Necessary).

7 Building/Facility Name/Designation Previous Tenant Name Building/Facility Address Item Description Indicate items included with this submittal for this building. Item Description Indicate items included with this submittal for this Fee Computations (doubled for installation without Required building approval) Check appropriate box and enter fee Fee Calculate the fees separately for each building 7. BUILDING SPECIFIC SANITARY: Select ONE of the following six options and enter the corresponding diameter or Drainage Fixture Units (DFU) and enter fee a. Interior Sanitary Drain and Vent System and Exterior Diameter of sanitary building sewer(s) in inches Sanitary Building Sewer x $50. b. Interior Sanitary Drain and Vent system only Diameter of sanitary building sewer, in inches, required to serve the building.

8 X $50. c. Interior Sanitary Drain and Vent system within an addition or DFU's new, added or relocated remodeled building See fee Table 1 in section 18 to convert DFU to a fee d. Multiple exterior Sanitary Building Sewers serving the DFU's new, added or relocated single building, and the interior Sanitary Drain and Vent system See fee Table 1 in section 18 to convert DFU to a fee e. Interior Sanitary Drain and Vent System with multiple DFU's new, added or relocated building drains exiting the building. No exterior sanitary sewers See fee Table 1 in section 18 to convert DFU to a fee SBD-6154 (R4/18) Page 2 Fee Subtotal SBD-6154 (R3/19) Page 2. 8. BUILDING SPECIFIC WATER. Select ONE of the following six options and enter the corresponding diameter or Gallons Per Minute (GPM) and enter fee a.

9 Interior Water Distribution system and Diameter of exterior water service in inches, or if serving a combination exterior Water Service domestic and fire sprinkler system, enter diameter of interior water distribution immediately after the meter or at the building control valve in inches x $50. b. Interior Water Distribution system, no Diameter of interior water distribution immediately after the meter or at exterior Water Service the building control valve in inches x $50. c. Interior Water Distribution system within an GPM added or relocated addition or remodeled building, no exterior Water See fee Table 2 in section 18 to convert GPM to a fee Service d. Multiple exterior Water Services serving the GPM.

10 Single building, and the interior Water Distribution See fee Table 2 in section 18 to convert GPM to a fee system e. Interior Water Distribution system with GPM. multiple Services exiting the building, no exterior See fee Table 2 in section 18 to convert GPM to a fee Water Services . 9. INTERCEPTORS. * No additional fee if submitted with Sanitary Drain & Vent Grease Interceptor(s) *Number of Grease Interceptors x $85, Garage Catch Basin(s) *Number of Garage Catch Basins x $85, Oil Interceptor(s) *Number of Oil Interceptors x $85, Car Wash Interceptor(s) *Number of Car Wash Interceptors x $85, Sanitary Dump Station(s) *Number of Sanitary Dump Stations x $85, Mixed Wastewater Holding Device(s) *Number of Mixed Wastewater Holding Devices x $85, Chemical System(s) (No Eyewash or emergency *Number of Chemical Systems x $85, showers).